A billion here and a billion there and pretty soon you’re talking real money. -Everett Derksen
My new patient looked very discouraged. I studied the reports from his treating physicians at the outside hospital.
“Doctor, what happens next? They told me that the cancer didn’t go away! The doctor who sent me said you would have to do a big surgery!” The questions poured from him. “I am just now feeling better. I can swallow and the pain is almost gone.”
I reviewed the outside studies and reports. He had presented with a cancer of the throat about four months before and he had undergone radiation and chemotherapy. “Let’s see … you finished your radiation and chemotherapy about a month ago, correct?”
He nodded. I checked his mouth and throat carefully and felt for enlarged lymph nodes in his neck. Indeed, his examination was perfect. There was no visible cancer anywhere.
“But, Doctor, what about the cancer they saw on the scan last week?”
Ah, the scan. I pulled up the images of the most recent PET/CT, a sophisticated study that merges images of the anatomy (the CT portion) with a PET scan that shows abnormal uptake in areas cancer or inflammation. Each PET/CT takes over an hour to perform and costs several thousand dollars. The scans often yield very valuable information and have become important in the evaluation and follow-up care of cancer survivors.
His recent scan did, indeed, still show activity in his throat with only slight improvement from the scan performed a week before his treatment.
I looked at him. This was going to be a complex discussion.
“The new scan is not very helpful,” I told him. “Research has shown that PET/CT is often misleading in your situation when performed earlier than three months after completing treatment. Patients with head and neck cancer treated with radiation and chemotherapy almost always show continued activity while the body is healing. After three months, the healing activity goes away and the scans become more helpful. I am pretty certain that is what we are seeing here…your body is still recovering.”
He stared at me silently, not knowing whether to believe me or his other physicians.
“You mean the test was useless?” He paused, apparently remembering the out-of-pocket costs. “Are we going to have to do repeat it in a couple of months?”
“Not necessarily,” I responded. “When you come for another appointment in a few weeks we’ll decide what kind of tests to perform based on how things look.”
Why had his previous physicians ordered the PET/CT so quickly after finishing his treatment? No doubt, they had never run across the data and recommendations buried deep in the medical journals. In addition, there is no system in place that flags expensive and marginally helpful tests to ask if they are truly indicated.There are also certain characteristics of “typical clinicians” that might help explain why we do not always practice the most appropriate and efficient care (see the JAMA editorial that is the source for the list):
(1) Physicians believe in what they are doing.
(2) Physicians prefer action, even with little chance of success, over no action at all.
(3) Physicians see apparent cause-and-effect relationships even when there are none.
(4) Physicians tend to rely on personal judgment more than evidence.
(5) When things go wrong, physicians tend to assign the bad outcome to chance.
I am no better than the next physician, especially in areas where I might not be expert. For people like me, we need to develop systems that block these types of errors. Although no one was hurt, plenty of money (both the patient's and the insurer's) was wasted.
Nationally, healthcare costs and health insurance costs are rising much faster than inflation. The combination of an aging population, complex and expensive healthcare technology, and limited success in promoting adherence to treatment guidelines will certainly drive costs even higher.
While the story here is an example of waste, it also provides a teaching moment that will improve medical care in the future. Too bad my patient had already undergone a very expensive and a very useless scan.
